Provider Demographics
NPI:1609087881
Name:PIBOOLNURAK, PANIDA (MD)
Entity Type:Individual
Prefix:
First Name:PANIDA
Middle Name:
Last Name:PIBOOLNURAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:910-662-7500
Mailing Address - Fax:910-662-7501
Practice Address - Street 1:1509 DOCTORS CIR
Practice Address - Street 2:BLDG C
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7403
Practice Address - Country:US
Practice Address - Phone:910-662-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-27
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC513482084N0400X
NC2016-01975207T00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ01970Medicaid
NC1609087881Medicaid
NCNCV432AMedicare PIN
NCNCV432BMedicare PIN
HI761N119381Medicare PIN